Effects of trauma-informed approaches in schools: A systematic review

1.1 The review in brief

Despite growing support and increased rate of which trauma-informed approaches are being promoted and implemented in schools, evidence to support this approach is lacking.

1.2 What is this review about?

Exposure to different types of trauma have been associated with varying types and complexity of adverse outcomes, including adverse effects on cognitive functioning, attention, memory, academic performance, and school-related behaviors. Given the growing research on trauma and increased knowledge about the prevalence, consequences and costs associated with trauma, there have been increased efforts at the local, state and federal levels to make systems “trauma-informed” (Lang, Campbell, & Vanerploeg, 2015). While the intent of creating trauma-informed approaches in schools is a noble one, relatively little is known about the benefits, costs, and how trauma-informed approaches are being defined and evaluated (Berliner & Kolko, 2016). Adopting a trauma-informed approach in a complex system such as a school building or district is a time consuming and potentially costly endeavor and thus it is important to assess the effects of this approach to inform policy and practice.

This aim of this review was to assess trauma-informed approaches in schools on trauma symptoms/mental health, academic performance, behavior, and socioemotional functioning. Trauma-informed approaches include programs, organizations, or systems that realize the impact of trauma, recognize the symptoms of trauma, respond by integrating knowledge about trauma policies and practices, and seeks to reduce retraumatization. At least two of the three key elements of a trauma-informed approach must have been present: Workforce development, trauma-focused services, and organizational environment and practices, which differ from trauma-specific interventions designed to treat or otherwise address the impact/symptoms of trauma and facilitate healing.

What is the aim of this review?

This Campbell systematic review sought to examine the effects trauma-informed schools on trauma symptoms/mental health, academic performance, behavior, and socioemotional functioning. Although we conducted a comprehensive search to find studies testing trauma-informed approaches in schools, no studies met the inclusion criteria.

2.1 Background

Exposure to different types of trauma have been associated with varying types and complexity of adverse outcomes, including adverse effects on cognitive functioning, attention, memory, academic performance, and school-related behaviors. Given the growing research on trauma and increased knowledge about the prevalence, consequences and costs associated with trauma, there have been increased efforts at the local, state and federal levels to make systems “trauma-informed” (Lang et al., 2015). Indeed, federal legislation has been proposed to advance trauma-informed practice, with approximately 49 bills introduced between 1973 and 2015 that explicitly mentioned trauma-informed practice, with more than half introduced in 2015 alone (Purtle & Lewis, 2017). The promotion and provision of trauma-informed approaches in school settings in particular is growing at a rapid rate across the United States. At least 17 states have implemented trauma-informed approaches at the school, district, and even state-wide levels (Overstreet & Chafouleas, 2016). This rapid increase in the growth of trauma-informed approaches in schools has been fueled by a number of local, state, and federal initiatives and increasing support by education related organizations. While the intent of creating trauma-informed approaches in schools is a noble one, relatively little is known about the benefits, costs, and how trauma-informed approaches are being defined and evaluated (Berliner & Kolko, 2016). Adopting a trauma-informed approach in a complex system such as a school building or district is a time consuming and potentially costly endeavor, and there is potential for harm; therefore, it is important to assess the effects of this approach to inform policy and practice.

2.2 Objectives

The purpose of this review was to identify, describe and synthesize the evidence of effects of trauma-informed approaches in schools to provide guidance for policymakers and educators and to identify important gaps in the evidence base.

2.3 Search methods

We conducted a search for published and unpublished studies using a comprehensive search that included nine electronic databases and searches of various research registers, gray literature sources, reference lists of prior reviews and relevant studies, and contacts with authors and researchers in the field of trauma and school-based intervention research.

2.4 Selection criteria

Criteria for inclusion in the review included:

1.

Must have used a randomized or quasi-experimental study design in which participants who received an intervention were compared with a wait-list, no treatment, treatment-as-usual or an alternative treatment comparison group.

2.

Studies must have been conducted in a school setting serving PreK-12 (or equivalent) students.

3.

Studies must have assessed effects of a trauma-informed approach, defined as a program, organization, or system that realizes the impact of trauma, recognizes the symptoms of trauma, responds by integrating knowledge about trauma policies and practices, and seeks to reduce retraumatization. At last two of the three key elements of a trauma-informed approach must have been present: Workforce development, trauma-focused services, and organizational environment and practices (Hanson & Lang, 2016). This approach is distinguished from trauma-specific interventions, which are specific interventions designed to treat or otherwise address the impact/symptoms of trauma and facilitate healing.

4.

Studies must have measured a student-level outcome related to trauma symptoms/mental health, academic performance, behavior, or socioemotional functioning.

5.

We did not limit studies based on publication status, geographical location or language. We searched for studies that had been published in the last 10 years, as this is a relatively recent movement

2.5 Data collection and analysis

One reviewer searched all sources and uploaded all potentially relevant citations to Covidence, a systematic review software, for further screening by two reviewers. Two reviewers then independently screened each of the full-text reports for eligibility using a screening instrument. Disagreements related to eligibility were discussed and resolved between the two reviewers. Data extraction and analysis was not possible due to no studies having met criteria for inclusion in the review.

2.6 Results

A total of 9,102 references from all searches were imported to Covidence for screening. After removal of 1,929 duplicates, 7,173 titles/abstracts were screened, and 7,106 studies were excluded. The remaining 67 studies were assessed for full-text eligibility by two independent reviewers. All 67 studies were excluded: 49 were neither an randomized controlled trial (RCT) nor quasi-experimental design (QED); 12 did not examine effects of a trauma-informed approach; 5 examined only one aspect of a trauma-informed approach (only workforce OR organizational OR practice changes); one was not a school-based intervention. Some studies may have been excluded for multiple reasons; however, only the first (primary) reason for exclusion was recorded. See Figure 1 for flowchart of the search and selection process. A full list of excluded studies can be found in References to Excluded Studies.

No studies met criteria for inclusion in this review.

2.7 Authors' conclusions

Trauma-informed approaches are being promoted and used across child-serving systems, and the number of states and school districts adopting trauma-informed approaches in schools is growing rapidly (Overstreet & Chafouleas, 2016). While the premise of a trauma-informed schools approach is a noble one, it is unclear as to whether the promise of this framework is actually delivering the types of systemic and programmatic changes intended, and if those changes are resulting in the outcomes the proponents of a trauma-informed approach in schools hoped for. The purpose of this systematic review was to find, describe, evaluate, and synthesize effects of trauma-informed approaches in schools to inform policy and practice. While there are a number of publications that describe trauma-informed approaches, advocate for the need for trauma-informed approaches, and discuss the potential benefits of adopting such an approach in schools, we found no rigorous evaluations through our extensive search process.

From this review, it seems like the most prudent action for school leaders, policymakers, and school mental health professionals to do would be to proceed with caution in their embrace of a trauma-informed approach as an overarching framework and begin evaluating these programs. We simply do not have the evidence (yet) to know if this approach works, and indeed, we also do not know if implementing trauma-informed approaches in schools could have unintended negative consequences for traumatized youth and school communities. We also do not have evidence of other potential costs in implementing this approach in schools, whether they be financial, academic, or other opportunity costs, and whether benefits outweigh the costs of implementing and maintaining this approach in schools.

That said, calling for caution in adopting a trauma-informed approach in schools does not preclude schools from continuing to implement evidence-informed programs that target trauma symptoms in youth, or that they should simply wait for the research to provide unequivocal answers. We do encourage healthy skepticism and evaluation by the schools who are adopting a trauma-informed approach and clear descriptions of what schools are doing. Currently, despite several theoretical and guidance documents, it is not clear exactly what schools are doing when they say they are using a trauma-informed approach. Not only do we need more research on the effects, but descriptive and qualitative research on what is actually being implemented would be a welcome addition to the empirical literature in this area. We suspect that schools may be calling what they are doing a trauma-informed approach, but what is actually being done from school to school or district to district may vary quite widely in the practice and implementation of this approach. Clearly, rigorous research is needed in assessing the effects of using a trauma-informed approach in schools and we encourage rigorously designed studies in this area. Evaluating complex interventions such as this is not easy and requires resources. Drawing from research on multi-tiered approaches in schools could help inform research approaches to assess the effects (and costs) of trauma-informed approaches in schools.

3.1 The problem, condition, or issue

Childhood trauma has been receiving increased attention and it is increasingly being recognized as a significant public health concern (Lang et al., 2015). Trauma exposure involves “actual or threatened death, serious injury, or sexual violence” that is either directly experienced or witnessed, learning that any traumatic experiences have happened to a loved one, or having repeated exposure to details of traumatic events (American Psychiatric Association, 2013, p. 271). Prevalence estimates of trauma experienced in childhood or adolescence vary by type of traumatic event (e.g., physical abuse, neglect, sexual abuse, witnessing violence, natural disasters) and how and when the traumatic experience is measured, but can range between 4% and 71% (Finkelhor, Turner, Shattuck, & Hamby, 2015; McLaughlin et al., 2013; Saunders & Adams, 2014). Prevalence and also vary by sociopolitical context as some countries are affected by war and have much higher levels of trauma (Bosqui, Marshoud, & Shannon, 2017).

Exposure to traumatic events can disrupt brain development and can have immediate and lifelong adverse effects on social, emotional, and physical wellbeing, including deficits in executive functioning, developmental delays, behavioral health problems, difficulty regulating emotions and behavior, academic performance and IQ, school behavior problems, delinquency, substance abuse, and mental health and psychiatric disorders (Anda et al., 2006; Delaney-Black et al., 2002; DePrince, Weinzierl, & Combs, 2009; Flannery, Wester, & Singer, 2004; Lang et al., 2015; Lansford et al., 2002). In a systematic review specifically examining school-related outcomes of traumatic event exposure, Perfect, Turley, Carlson, Yohannan, and Gilles (2016) identified 44 studies that examined cognitive functioning, 34 that examined academic functioning, and 24 that examined social-emotional-behavioral functioning. Their findings suggest that youth who have experienced trauma are at significant risk for impairments across various cognitive functions, including IQ, memory, attention and language/verbal ability; poorer academic performance and school-related behaviors such as discipline, dropout and attendance; and higher rates of behavioral problems and internalizing symptoms.

Exposure to different types of trauma have been associated with varying types and complexity of adverse outcomes. Kira, Lewandowski, Somers, Yoon, and Chiodo (2012) study of African American and Iraqi refugee youth found that different types of trauma differentially impact different components of cognitive functioning, including perceptual reasoning, working memory, processing speed and verbal comprehension. In another study examining effects of different types of trauma, exposure to violence was found to be associated with depression, separation anxiety, and conduct problems, whereas exposure to noninterpersonal traumatic events was associated with phobic anxiety (Briggs-Gowan et al., 2010). Moreover, there is some evidence that the effects of trauma are cumulative, thus youth who experience a greater number of traumatic events are more at risk for adverse outcomes and more complex symptoms through adulthood (Chartier, Walker, & Naimark, 2010; Cloitre et al., 2009; Hodges et al., 2013). Duke, Pettingell, McMorris, and Borowsky (2010) analyzed data from respondents to the 2007 Minnesota Student Survey (n = 136,549), and identified “a significant positive relationship between each adverse event and delinquent behaviors for girls and boys,” (p. e782). The effects of cumulative trauma also go beyond frequency, as the type, severity, and duration of trauma has been shown to be important (e.g., childhood sexual abuse has been found to have a stronger association with negative adult outcomes than other forms of abuse and neglect; Bebbington et al., 2004; Bosqui et al., 2014).

While exposure to traumatic or potentially traumatic experiences are associated with a range of short and long-term outcomes, there are multiple pathways through which trauma can impact various domains across the life course. Moreover, not all youth will experience the same traumatic events in the same way and not all youth will develop symptoms following a traumatic experience (Layne et al., 2009).

Given the growing research on trauma and increased knowledge about the prevalence, consequences and costs associated with trauma, there have been increased efforts at the local, state, and federal levels to make systems “trauma-informed” (Lang et al., 2015). In an effort to examine the extent to which federal legislation has been proposed to advance trauma-informed practice, Purtle and Lewis (2017) conducted a policy mapping study of federal legislative proposals from 1973 to 2015 that explicitly mentioned trauma-informed practice. The authors identified 49 bills introduced, beginning in December 2009 with the Domestic Minor Sex Trafficking Deterrence and Victims Support Act, and observed a dramatic increase over time with 28 bills being introduced in 2015 alone. Altogether, the 49 bills contained 71 sections that included trauma-informed language, with the highest proportion of those specifically targeting youth in primary and secondary schools (16 sections, 22.5%). For example, the United States Congress established the National Child Traumatic Stress Network (NCTSN) in 2000 through a congressional initiative that is funded by the Substance Abuse and Mental Health Services Administration (SAMHSA). The National Child Traumatic Stress Network (n.d.a) is a growing network of providers, researchers, and families with a broad mission to improve care and access to services for traumatized children, their families, and communities. The NCTSN offers training, support, and resources aimed at treatment, intervention development, program evaluation, systems change, and the integration of trauma-informed and evidence-based practices in all child-serving systems. The Administration for Children and Families, Center for Medicare and Medicaid Services, the Department of Justice, and the Department of Education have also recognized the impact of child trauma on youth wellbeing and development and are launching initiatives and implementing policies designed to promote the use and expansion of trauma-informed systems and programs across child-serving organizations and agencies (Lang et al., 2015; Substance Abuse and Mental Health Services Administration, 2014).

The promotion and provision of trauma-informed approaches in school settings is growing at a rapid rate across the United States. At least 17 states have been identified in which trauma-informed approaches have been implemented at the school, district, and even state-wide levels (Overstreet & Chafouleas, 2016). This rapid increase in the growth of trauma-informed approaches in schools has been fueled by a number of local, state, and federal initiatives and increasing support by education related organizations. For example, there are explicit provisions for trauma-informed practices in the Every Student Succeeds Act (Every Student Succeeds Act, 2015), the legislation that replaced No Child Left Behind, including training of school personnel in understanding when and how to refer students affected by trauma, and grant programs that provide funding to support services that are based on trauma-informed practices that are evidence-based (section 4108). The promotion of trauma-informed schools is also supported by the National Education Association and state-level agencies have been spearheading efforts to develop guidelines and implement change within and across school systems.

Globally, there is understanding of the impact of trauma on children and the consequences for the school environment. For example, multiple systems in Australia (child welfare, disability support, human services, mental health, legal context) have identified the need for using a trauma-informed lens in practice. The Queensland, Australia educational system was particularly interested in ensuring that the educational and mental health needs were met for children living in out-of-home care and children with complex trauma histories and therefore looked to a trauma-informed framework as a possible intervention to meet these needs. Prompted by limited success in meeting the challenges schools in Australia face with students with serious behavior concerns, the Queensland University of Technology and the Department of Education in Queensland conducted a study to explore the understanding and need for trauma-aware schooling and identified the need for comprehensive training and support for school personnel (Howard, 2018).

In the United Kingdom, to improve the connection between mental health services and the education system, the Department for Education and National Health Service have conducted multiple surveys and pilot projects in attempts to provide greater school-wide approaches to promote mental health and wellbeing for children. They have identified trauma, attachment, and post-traumatic stress as key areas where schools need guidance (Department of Health & Department for Education, 2017). In response to the publication of the Department of Education and National Health Service, organizations such as the Center for Mental Health responded, urging the Government to put forth the adequate resources to implement whole school approaches and not only invest in trauma-focused interventions, but to also address the underlying causes that contribute to children's mental health (Hughes, n.d.).

In areas of the world where there is conflict, emergency, and crisis, both children and adults see schools as places of refuge, learning, and paths to better futures. International organizations such as Save the Children have identified education as priority for children and they urge both national governments and humanitarian actors to ensure that children have access to schooling and to ensure schools are providing the appropriate mental health support (Save the Children, 2015). The United Nations Girls' Education Initiative in the East Asia Pacific Region, which aims to ensure that both boys and girls receive primary and secondary education, have identified the need for additional support services for those who have experienced trauma (Clark & Sawyer, 2014). With limited resources and surrounding conflict, the knowledge of what environment would best support children's learning may be understood, but the lack of resources may prevent schools from implementing trauma-informed approaches.

3.2 The intervention

Trauma-informed approaches are being promoted and used across child-serving systems and constitute a relatively new approach to trauma care for children and youth being served within the child welfare, juvenile justice, mental health, and education systems. While trauma-specific interventions, such as Trauma-Focused Cognitive Behavioral Therapy, are well known and widely used to treat trauma-related symptoms and disorders in both adults and children, trauma-informed approaches to care are distinct from trauma-specific interventions. However, what is essential to a “trauma-informed approach” has not always been clearly operationalized, and the approach and variations of the approach have been referred to in varying ways, for example, “trauma-informed care,” “trauma-sensitive,” “trauma-informed system” (Hanson & Lang, 2016). To date, there is no consensus on the use of these terms, which makes efforts to both implement and study trauma-informed approaches to care challenging.

While there is much confusion, overlap and misuse of the various terminologies in this rather nascent area of practice and research, we are drawing from SAMHSA and the NCTSN to define trauma-informed approaches for the purpose of this review. Substance Abuse and Mental Health Services Administration (2014) defines trauma-informed approaches (which the agency uses interchangeably with “trauma-informed care”) as incorporating “key trauma principles into the organizational culture” of the program, agency, or system (p. 9). A trauma-informed approach is thus more akin to a multi-tiered framework such as School-Wide Positive Behavioral Supports (Chafouleas, Johnson, Overstreet, & Santos, 2016), and is based on incorporating four key assumptions and six key principles, generalizable to any setting, that are infused across all levels of an organization rather than implementing a prescribed set of practices or interventions (Substance Abuse and Mental Health Services Administration, 2014; see Figure 1).

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1

SAMHSA's trauma-informed approach (Lang et al., 2015). SAMHSA, Substance Abuse and Mental Health Services Administration

A trauma-informed program, organization, or system is one that (Substance Abuse and Mental Health Services Administration, 2014, p. 9): 1.

Realizes the widespread impact of trauma and understands potential paths for recovery;

The six key principles of a trauma-informed approach include safety; trustworthiness and transparency; peer support; collaboration and mutuality; empowerment, voice and choice; and cultural, historical, and gender issues (Substance Abuse and Mental Health Services Administration, 2014).

The National Child Traumatic Stress Network (n.d.b) adapts the model outlined by SAMHSA to a context specific to youth and families, and describes their model as a “trauma-informed child- and family-service system,” in which:

all parties involved recognize and respond to the impact of traumatic stress on those who have contact with the system, including children, caregivers, and service providers. Programs and agencies within such a system infuse and sustain trauma awareness, knowledge, and skills into their organizational cultures, practices, and policies. They act in collaboration with all those who are involved with the child, using the best available science, to facilitate and support the recovery and resiliency of the child and family.

In essence, a trauma-informed approach is not a standalone intervention that can be delivered in isolation, but rather a framework to guide systems. A trauma-informed approach can include trauma-specific interventions, but trauma-specific interventions alone are not seen as sufficient for achieving optimal outcomes or to influence service systems (Substance Abuse and Mental Health Services Administration, 2014). Hanson and Lang (2016) identify three core domains essential to trauma-informed care that they derived from analyzing definitions and components across several organizations and authors, including SAMHSA and NTCSN: (a) Workforce/professional development (PD), (b) organizational changes, and (c) practice changes.

Examples of trauma-informed approaches implemented in schools

As described above, trauma-informed approaches are complex interventions and involve a number of components at various levels, thus providing some examples of such programs can be helpful in elucidating this complexity. One example of a trauma-informed approach is the Healthy Environments and Response to Trauma in Schools (HEARTS) program that was implemented in elementary schools (K-8th grade) in the San Francisco Unified School District. HEARTS is a whole-school program developed by the University of California, San Francisco to promote school success for students who have been impacted by trauma (Dorado, Martinez, McArthur, & Leibovitz, 2016). This whole-school approach used the response to intervention three-tier framework of universal, selected and targeted interventions and included supports at the system, adult (teacher/staff) and student levels at each tier. Activities involved changes in school policies and school-wide practices; training, PD, and consultation for all school staff around trauma-sensitive practices and stress, burnout and secondary trauma; and use of evidence-informed universal, secondary and targeted trauma-informed interventions. TRUST in Schools: Trauma, Understanding & Sensitive Teaching is an example of a trauma-informed school approach being piloted in Australia (Harris, n.d.). This program focuses on recognizing the impact of trauma on children across the whole school, a school executive that promotes trauma-sensitive policies and procedures in the school, supporting school staff in implementing sensitive practices and engaging families, carers, and school communities in understanding the need for a trauma-sensitive whole school approach.

Trauma-informed approaches are also used at the preschool level. A multiorganization collaboration implemented a trauma-informed approach in head start programs in the Appalachian region of the US (Shamblin, Graham, & Bianco, 2016). This comprehensive, three-tier model involved the use of trained consultants in the classroom to provide three tiers of services. The first tier was universal consultation, intended to build teacher capacity to deliver an evidence-based social-emotional curriculum (Second Steps or Incredible Years) to children and help teachers understand trauma-informed principles through training and mentoring of teachers. The second tier involved targeted consultation of teachers to develop behavior plans and specific strategies to address challenging behaviors of individual children in the classroom which take into account the child's trauma experience. The third tier included the provision of intensive services wherein the consultant provided on-site mental health assessment and treatment to children and their families. For children who had experienced trauma, the consultant provided Trauma-Focused Cognitive Behavior Therapy and/or Parent–Child Interaction Therapy. In addition, the collaboration provided workforce development training to preschool teacher and other child service providers at various times during the year.

While schools may be implementing trauma-informed approaches, it is unclear to what extent or how much variation there is in what schools are implementing or how much emphasis they are putting on various components (e.g., workforce development versus organizational change versus practice changes) and whether schools may implement trauma-informed approaches differently based on the characteristics of their students, neighborhood, country or other contextual factors.

One out of every four children attending school has been exposed to a traumatic event, which can impact school performance, impair learning, and cause physical and emotional distress (NCTSN, 2008). Moreover, the majority of youth who have experienced trauma do not receive services, and those who are exposed to a potentially traumatic event do not necessarily need an intervention (Layne et al., 2009). Due to the relatively high rates of youth exposed to traumatic events and the negative impacts of those traumatic experiences on academic achievement and life course outcomes, schools represent a natural system in which to help prevent and reduce the adverse effects of trauma and more effectively engage students in the learning process (Chafouleas et al., 2016). Trauma-informed schools adopt the trauma-informed approach to “create educational environments that are response to the needs of trauma-exposed youth through the implementation of effective practices and system-change strategies” (Overstreet & Chafouleas, 2016, p. 1). A trauma-informed approach in schools is designed to create a systematic model for schools to decrease the impact of trauma on students (Wiest-Stevenson, & Lee, 2016) and more appropriately address academic, behavioral and socioemotional problems by recognizing and responding to student behavior from a trauma-informed perspective. This is done through a multilevel approach intended to improve the school environment through implementing trauma-informed policies and procedures; increase the ability of school staff to recognize and more effectively respond to students through PD; and prevent, mitigate and reduce trauma-associated symptoms through evidence-informed practices, leading to improved student academic, behavioral, and socioemotional outcomes.

As described above, a trauma-informed approach involves strategies implemented at various levels in the school and includes workforce/PD, organizational change, and practice change using evidence-informed practices (Hanson & Lang, 2016).

3.4 Why it is important to do the review

Although one could argue about the necessity or value of schools adopting a trauma-informed approach, trauma-informed approaches are being promoted and used across child-serving systems, and the number of states and school districts adopting trauma-informed approaches in schools is growing rapidly (Overstreet & Chafouleas, 2016). While the intent of creating trauma-informed approaches in schools is a noble one, there is relatively little known about the benefits, costs, and how trauma-informed approaches are being defined and evaluated (Berliner & Kolko, 2016). Indeed, it is unclear whether schools adopting a trauma-informed approach (i.e., being a “trauma-informed school”) are effective in reducing trauma symptoms or affecting behavioral or academic outcomes, as the proponents of the movement propose. Adopting a trauma-informed approach in a complex system such as a school building or district is a time consuming and potentially costly endeavor and thus it is important to assess the effects of this approach to inform policy and practice. Also, from our cursory review of the literature, the description of the trauma-informed approaches being implemented in schools vary in terms of the types of strategies used in each of the three areas and the relative emphasis on the three areas (policy/procedures, PD, and practices), thus it is important to conduct a systematic inventory and description of the trauma-informed approaches implemented in schools to more fully understand how this approach is being utilized in schools, and whether variations in the components impact outcomes.

To date, we have not located any systematic reviews specifically examining effects of trauma-informed approaches in schools. We have identified reviews that have examined trauma-specific interventions for adolescents (e.g., Black, Woodworth, Tremblay, & Carpenter, 2012; Cary & McMillen, 2012) and those that examine school-based interventions for specific trauma-related disorders, such as PTSD (e.g., Rolfsnes & Idsoe, 2011); however, these reviews are examining effects of trauma-specific interventions rather than trauma-informed approaches. By virtue of these studies' primary research questions and inclusion criteria, the scope of these reviews were not designed to examine effects of a trauma-informed approach in schools.

5.1 Criteria for considering studies for this review

A protocol for this review was published in the Campbell Collaboration Library (Maynard, Farina, & Dell, 2017).

5.2 Search methods for identification of studies

We conducted a search for published and unpublished studies using a comprehensive search that included multiple electronic databases, research registers, gray literature sources, and reference lists of prior reviews and relevant studies, and contacts with authors and researchers in the field of trauma and school-based intervention research.

5.3 Data collection and analysis

6.1 Description of studies

6.1.1 Results of the search

A total of 9,102 references from all searches were imported to Covidence for title and abstract screening. After removal of 1,929 duplicates, 7,173 titles/abstracts were screened by one reviewer and 7,106 reports were excluded. Two reviewers then screened the full text of the remaining 67 reports. All 67 reports were excluded: 49 were neither an RCT nor QED; 12 did not examine effects of a trauma-informed approach; 5 examined only one aspect of a trauma-informed approach (only workforce OR organizational OR practice changes); one was not a school-based intervention. Some studies may have been excluded for multiple reasons; however, only the first (primary) reason for exclusion was recorded. See Figure 2 for flowchart of the search and selection process. A full list of reports excluded at the full-text screening stage can be found in References to Excluded Studies in the References section.

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Search and selection flowchart

No studies met criteria for inclusion in this review.

No studies met inclusion criteria, thus no studies were assessed for risk of bias.

6.3 Synthesis of results

No studies met inclusion criteria for this review, thus no synthesis was conducted.

7.1 Summary of main results

Trauma-informed approaches are being promoted and used across child-serving systems, and the number of states and school districts adopting trauma-informed approaches in schools in the US and other countries is growing rapidly (Overstreet & Chafouleas, 2016). While the premise of a trauma-informed schools approach is a noble one, it is unclear as to whether the promise of this framework is actually delivering the types of systemic and programmatic changes intended and if those changes are resulting in the outcomes the proponents of a trauma-informed approach in schools hoped for. The purpose of this systematic review was to find, describe, evaluate and synthesize effects of trauma-informed approaches in schools to inform policy and practice. Despite our extensive search for studies, we found no studies that met criteria for inclusion in this review. While there are a number of publications that describe trauma-informed approaches, advocate for the need for trauma-informed approaches, and discuss the potential benefits of adopting such an approach in schools, there have been no rigorous evaluations of trauma-informed approaches in schools that we could find.

While the paucity of rigorous research in this area is disappointing, it is not altogether surprising. The adoption of a trauma-informed approach is relatively new and it is likely that there has not been sufficient time for the research to catch up to the enthusiasm for this approach in schools. Furthermore, conducting rigorous research on multi-component and multi-tiered approaches can be complex and expensive, often requiring large grants to help fund the research, which can also delay the conduct of rigorous research.

7.2 Overall completeness, applicability, and quality of evidence

We found no studies that met eligibility criteria, thus the evidence in this area is completely lacking.

7.3 Limitations and potential biases in the review process

While this review sheds light onto the lack of evidence available to inform policy and practice regarding trauma-informed approaches in schools, the present study is not without limitations. Despite our attempts at a comprehensive search process, there is the possibility that we may have not captured every potentially eligible study; however, we believe the risk is quite small given the extensive search process. Anecdotally, we are aware of some ongoing studies, but there are no protocols published to provide more information about these studies in this review. This review was limited to studies that included at least two of the three components of a trauma-informed approach (workforce/PD, organization change or practice change), thus we may have excluded studies that authors themselves or others may consider a trauma-informed approach.

8.1 Implications for practice and policy

From this review, it seems like the most prudent thing for school leaders, policymakers, and school mental health professionals to do would be proceed with caution in their embrace of a trauma-informed approach as an overarching framework and conduct rigorous evaluation of this approach. We simply do not have the evidence (yet) to know if this works, and indeed, we do not know if using a trauma-informed approach could actually have unintended negative consequences for traumatized youth and school communities. We also do not have evidence of other potential costs in implementing this approach in schools, whether they be financial, academic, or other opportunity costs, and whether benefits outweigh the costs of implementing and maintaining this approach in schools. That said, calling for caution in adopting TIC in schools does not preclude schools from continuing to implement evidence-informed programs that target trauma symptoms in youth, or that they should simply wait for the research to provide unequivocal answers. The benefit of the trauma-informed approach being made freely available by SAMHSA and other policymakers is that these components can form the basis for a school (or school district) to begin to adapt and apply this approach in schools.

An additional potential space for implementing a trauma-informed approach could be within the various 3-tier models currently active in schools (often referred to as multi-tiered systems of supports [MTSS]) to give some form and structure to these efforts. Indeed, recent scholarship has argued for the trauma-informed approach to be embedded within MTSS to take advantage of the primary prevention focus inherent in MTSS Tier 1 and Tier 2 efforts, along with the use of data via screening tools to identify students who are impacted by trauma (Cavanaugh, 2016; Stephan, Suagi, Lever, & Connors, 2015; Zakzeski, Ventresco, & Jaffe, 2017). The process of screening students for trauma is not without its own controversy; however, as parent groups and school stakeholders sometimes oppose the idea of screening youth in schools for issues that they believe are the domain of parents and mental health systems to handle (Dowdy, Ritchey, & Kamphaus, 2010).

8.2 Implications for research

The implications for research are clear: Trauma-informed interventions need to be rigorously evaluated. Anecdotally, we are aware of some studies currently underway that are trying to evaluate various components of the trauma-informed approach in schools; however, neither protocols nor the completed studies have been published. Given the complexity of this approach and knowledge about research of other multi-component and MTSS in schools, such as Positive Behavioral Interventions and Supports and Response to Intervention, researchers could draw from lessons learned in the conduct of research with these approaches to help inform future studies of trauma-informed approaches. We also encourage studies that examine the implementation of trauma-informed approaches in schools. Examining what schools are doing, how they are implementing trauma-informed approaches, and variations in components being included is important to understanding whether and how trauma-informed school approaches work and what is required to successfully implement this approach in schools.

8.3 Roles and responsibilities

Please give brief description of content and methodological expertize within the review team. The recommended optimal review team composition includes at least one person on the review team who has content expertize, at least one person who has methodological expertize and at least one person who has statistical expertize. It is also recommended to have one person with information retrieval expertize.

Who is responsible for the below areas? Please list their names:

Content: All authors were responsible for the substantive content related to trauma-informed schools.